(Guest Lecture): July 2022 - What Diet to Follow After Stem Cell Transplant

So today's topic is what diet to follow after stem cell transplant. The previously restrictive neutropenic diet once followed after stem cell transplants is no more. With more understanding and data published, nutritionists and dietitians alike have adjusted the post-transplant diet to include more nourishing and beneficial foods. Today we're going to learn about what foods are good to eat, what precautions should be taken when it comes to feeding yourself or a loved one, and we're going to answer your questions. So Lauren Fay, RD, CSO, CNSC, is an oncology registered dietitian who currently practices at the Inova SCARS Cancer Institute and Life with Cancer in Fairfax, Virginia. Lauren graduated from James Madison University with a bachelor's degree in dietetics and completed her dietetic internship at Beth Israel Deaconess Medical Center in Boston, Massachusetts. Lauren has spent her 13-year career in oncology nutrition supporting the nutrition needs of oncology patients in both the inpatient and outpatient setting. She is board certified in oncology nutrition as well as nutrition support and is currently working towards her master's degree in public health with a focus on health policy from George Mason University. That being said, we are really looking forward to hearing from you, Lauren, and I will turn the time over to you now. Excellent. Thank you for that introduction, and I'm going to go ahead and get started by sharing my screen. All right. So as Audrey introduced, the topic today is an important one to talk about nutrition and diet considerations following a stem cell transplant. Sorry, just really fast. We got to go to the display settings and switch them. Oh, sorry. No, it's okay. There we go. Are we good? Yes. Yeah, we're good. Fantastic. All right. So today we're going to be talking again about a very important topic and provide some clarification about diet guidance following a stem cell transplant. And this is actually bringing me very full circle in my career as I started my career as an oncology dietitian working directly with stem cell transplant patients in Boston. So this is bringing me back to some of the evolution of these recommendations, even in the relatively speaking short 13 years that I've been working. So I often like to start my presentation by addressing one of the biggest challenges with any oncology nutrition topic. This one very much included, which is what makes it so hard to know what to eat in many of these settings during active treatment, recovery and survivorship. And so one of the things I like to acknowledge is that really for anyone in our society, but particularly after a diagnosis like multiple myeloma or any other form of malignancy and during these really challenging treatments, we often are bombarded with so many different resources trying to inform us of what we should do from a nutrition standpoint. And one thing I often tell my colleagues is that I don't question the intent of really any of these sources that are sharing information, whether it's friends and family members, clinicians that you're seeing in the many different appointments that you're going to, or even resources you're trying to find yourself on the internet or libraries. But what could be really confusing and stressful for individuals on the receiving end is when you're seeing mixed messages about what you should do. And so that's really one of the most important roles of an oncology dietitian is to help provide that clarification of correctly interpreted evidence-based recommendations as it relates to nutrition during different times in cancer treatment, recovery and survivorship. So with that said, the focus of our conversation today will be to explain the most up-to-date information and guidance on food safety following stem cell transplant, as this, like I said earlier, is something that has evolved even in the time that really I've been practicing, address other really important nutrition concerns following stem cell transplants, and talk about those priorities, when and how they change and how that might affect what you choose to make priorities within your diet. And then maybe most importantly, providing you with reliable resources for evidence-based nutrition counseling, education resources, and other forms of resources to help you nutritionally wherever you are in that continuum. So let's start with a little bit of history of food safety guidance after stem cell transplants. So the history of what has been referred to most frequently as the neutropenic diet actually goes back decades. Now, many of you, I'm sure, are aware based on your clinical course, what the word neutropenia means, but just for a very quick review, this is when you have too few of what are called neutrophils, which are one of the types of our white blood cells. They are one of the white blood cells that are most important for helping us fight infection, and especially those caused by bacteria. So initially, when chemotherapy and agents that would cause low counts of neutrophils or neutropenia were being studied, particularly in animal models back in the 1960s and the 1970s, the researchers identified that when those white blood cell counts were low, it was more common for bacteria to what's called translocate or go from inside our gastrointestinal tract outside into our bloodstream leading to infection. This led the researchers to advise medical oncologists prescribing chemotherapy and then eventually undergoing and, sorry, eventually helping with administering stem cell transplants to indicate that they should be advising their patients to restrict any potential for bacteria to enter someone's GI tract. This was a very well-intentioned effort. The, you know, again, goal of this was to ultimately reduce risk for infections, which can be very dangerous and have very severe consequences when neutrophils are low and experiencing neutropenia. But as this last line states here, this continued for decades to theoretically reduce that risk of infection. So a little bit of background before we talk about the most up-to-date data is the concept that there's also no universal definition of what we call a neutropenic or in some health systems they refer to as a low bacteria diet. However, most of these diets historically and certainly early on in my career were characterized by restrictions of enormous groups of foods, including things like all fresh fruits and vegetables, oftentimes things like herbs and seasonings, and requiring lots of prepackaging and cooked or in some of my patients' opinion overcooked foods in order to reduce this risk for infection. Now, as I stated before, this was a theoretical intervention to reduce risk for infection. But around the, you know, turn of the century, early 2000s, clinicians such as dietitians and people involved in groups administering chemotherapy and stem cell and performing stem cell transplants really wanted to ask whether this restriction was necessary and was it actually reducing incidence of infection. And so over the past two decades, there have been many more studies conducted in humans identity trying to identify whether these restrictions were in fact protective against reducing risk for infections, because certainly if they were, we needed to continue to utilize them. But if they were not, these were probably unnecessary restrictions that were limiting diets for individuals that often have a hard time eating enough to begin with due to treatment-related side effects. So over these two decades, these trials were conducted in all levels, age groups, and types of individuals who became neutropenic as a result of chemotherapy, including during stem cell transplants. And what these studies found was that pretty universally within adults, pediatrics, all types of chemo and stem cell transplant, these restrictive diets did not show a reduction in risk for or rates of infection. So I've listed here a study that was published back in 2019. That's something called a meta analysis of randomized controlled trials. Randomized controlled trials, as many of you may be familiar, are our gold standard for research to show true impact of an intervention. So these are really our highest quality human trials. And then a meta analysis is something that strengthens that data even further by bringing together many of these studies to see if they're showing the same thing. What this meta analysis found, again, showed no overall reduction in risk for or rates of infection. So we really have proven through good quality research that unfortunately these diets that were extraordinarily well-intentioned to begin with did not in fact provide that protection that they were trying to accomplish. So based on these updated research reports and meta analyses of randomized controlled trials, the American Society of Clinical Oncology, otherwise known as ASCO, as well as the Infectious Diseases Society of America updated their practice guidelines for what's called antimicrobial prophylaxis for adults patients with cancer-related immunosuppression. So this means what they recommend to help reduce risk for infection for cancer-related immunosuppression, which is something that happens with the impact of chemotherapy, including during stem cell transplant. These guidelines that were updated in 2018 advised against neutropenic diets within the guidelines. This report, these guidelines, as well as the meta analysis I just referenced, are two pieces of literature that I'm going to be including in the resources that I provide to Audrey. So you will have copies of if interested in terms of reviewing after this presentation. So this said, we obviously know when an individual is neutropenic or immunocompromised, there is clearly a higher risk for infection overall, whether it comes from food or not. And we do know that the consequences can be much more severe if they experience a foodborne illness during that period of time. So for that reason, it is important that we are still taking food safety precautions very seriously during these times to help reduce that risk. I use that verbiage risk reduction very intentionally because unfortunately, we cannot completely eliminate this risk, but there's many things we can do to help with reducing the risk for infection, which is something that absolutely is advised during neutropenic time periods. But to be honest, really at all times in our life to help with reducing risk for a foodborne illness. And so these food safety practices continue to be recommended, even if the historical, very restrictive, neutropenic diets are no longer something we recommend. So what are these food safety guidelines I'm referring to? So another resource I'm going to be providing with this information is a really nice comprehensive packet from the FDA that reviews food safety recommendations for individuals with cancer and those people that might be intermittently neutropenic, including during and following a stem cell transplant. These resources are also available on the Internet on foodsafety.gov, in addition to a lot of other helpful tools that you can utilize for reliable resources to help with risk reduction of experiencing a foodborne illness. This is a nice infographic available from the FDA that goes through really the most important components of food safety, as well as some of the other statistics they found important to share, particularly as an individual who may be neutropenic as a result of cancer related therapies. So they start by offering some statistics about the amount of people that do get sick from foodborne illnesses, which some people might be surprised is actually quite common. So one in six Americans every year get sick from these illnesses. It's important to pay attention to symptoms of a foodborne illness, although this can be a little bit complicated because these are symptoms that can result from other forms of infection as well as treatment related side effects. Ongoing communication with your treatment team about any new symptom is always advised so that they can evaluate the potential cause. One of the biggest categories of foods that we focus on when it comes to food safety is animal protein. So things like red meat, poultry, fish, and so making sure that those internal temperatures are reaching the appropriate level as listed here under the safe minimal internal temperatures portion of this chart is really critical to reduce risk for foodborne illness from any bacteria that may still be in that food. They also have a nice summary with infographic pictures here of foods we still recommend avoiding and foods that are completely fine to eat. So just briefly going down and highlighting some of the most important ones in terms of avoidance, continuing to avoid things that are raw, undercooked in terms of meat, poultry, or seafood are advised. Any unpasteurized or raw milk, and so that's something that you can identify based on the label. There's an increased popularity in getting milk directly from farms. I know in many areas of the country this would be something that it really would be advisable to ensure that that milk is being pasteurized and any unpasteurized products are not consumed during this period of time when you're at risk for foodborne illness. Raw or undercooked eggs continue to be not advised both even when you're preparing them but just being mindful of things like salad dressings and that can incorporate eggs that are not fully cooked. Unwashed fresh produce, so I do want to highlight that yes unwashed fresh produce or certainly any produce that has evidence of things like mold or contamination are not advised but historically sometimes there were institutions that were advising against any fruits or vegetables to be consumed during this period of time and that is not the case. As long as they are well washed and certainly if they are well washed and cooked that infection risk is very low and you can absolutely still consume these foods. Soft cheeses made from unpasteurized or raw milk. This is a little bit of a tricky category that I frequently get questions about and really the best advice I have for you here is pay close attention to the labels of whatever cheeses that you're purchasing. If it is not clearly indicated that it's made from pasteurized milk it is something that I would not advise consuming. We used to be able to distinguish this based on types of cheese but now a lot of those lines have become blurred because even some cheese that historically weren't pasteurized there are now pasteurized forms of. If it's ever not clear to you on the package itself every package should have a number to contact the producers of that food so you should be able to contact the company themselves to say hey how was this treated prior to packaging. Cold hot dogs and deli meats. So there's a really tricky bacteria that even with cooked meats when it's packaged in those forms can still survive called Listeria. So things like the hot dogs and deli meats should be cooked additionally prior to consuming to reduce risk for that particular type of bacteria or you could always simply eat your animal protein in a different form meaning something like a chicken breast rather than chicken breast deli meat that's pre-packaged. And then the one small exception to no plants is raw sprouts. So bean sprouts, alfalfa sprouts, these are a little bit of a tricky plant that are very commonly run a high risk of foodborne illness and for that reason that's one of the few foods we really do advise limiting or avoiding consumption of during periods of time where you are at higher risk for infection. So again one of the few exceptions to the rule. I do often like to focus not on what we can't eat but really what we can consume because once again these treatments can come with so many side effects that are already impacting your ability to eat enough and so focusing on the things that are still well within the safety of consuming is really important. So all cooked meat poultry and seafood are completely fine to consume. Pasteurized milk and milk products so things like yogurt, ice cream, pasteurized cheeses are all completely fine. Cooked eggs with a firm yolk so hard-boiled eggs, scrambled eggs, omelets, washed fresh or cooked produce, hard cheeses or soft cheeses made from pasteurized milk, reheated hot dogs and deli meats up to 165 degrees or steaming if you will and then cooked sprouts. So again this is not particularly limiting in many respects and definitely not nearly as limiting as it used to be in terms of this guidance for individuals going through stem cell transplant and afterwards during recovery. Now a few practical considerations I want to talk about. You know the infographic I just showed had some nice questions to discuss with your treatment team and I want to kind of further talk about the importance of discussion with your treatment team about any guidance you might be receiving. It has been my experience working at three large cancer institutes that many clinicians involved in your care often offer guidance again about what you should be consuming and unfortunately those that aren't nutrition experts sometimes aren't familiar with all of the most up-to-date data. So in my experience individuals often in passing will hear from a nurse or even an oncologist, oh you can't eat blank right. I would encourage you to ask them what the reasoning is behind that and even now feel a little bit empowered to share with them you know I actually attended a presentation that said that this is the most up-to-date guidance. Is this something that you agree with and certainly have that discussion in regards to their concerns and perhaps providing them a piece of education as well. Most transplant institutions in the United States have eliminated neutropenic diets or low bacterial diets but certainly not all of them. This was something that actually coming to my current cancer institute we eliminated when I started about four years ago so not too many years. So again this is something that's evolving with the science and making sure that they're up to date on this guidance is important and having that open communication. And then the second point here in terms of a practical implication is discussing with anyone preparing foods for you. So it's often great to get assistance from family members and friends in the community that are trying to help you with you know making sure that you have food options available particularly when you're fatigued and your caregivers have a lot of responsibility. So just make sure that they're aware of these safety precautions as well. I get a lot of questions in regards to things like restaurants or takeout and my overall you know advice would be if you're unsure or have concerns about food safety practices at that place it's probably not a good time to be eating at that location. Please you know it is absolutely your right and responsibility to ask you know restaurant members, staff members, chefs or anyone preparing your food about their food safety practices and if you don't feel confident in the advice that they're giving you probably not a good time to eat there. All right and other nutrition considerations following stem cell transplant. So two other big categories that I really wanted to touch on and certainly provide resources for are really based on where you are in your recovery period following stem cell transplant. So what I mean by that is that even after discharge from a stem cell transplant oftentimes people still experience some of the side effects that can impact getting enough calories and protein to maintain weight after the stem cell transplant procedure and so things what I'm referring to are things like a decline in appetite, sometimes getting full quicker, things like nausea, taste changes, bowel movement abnormalities and so in the setting of these side effects it can be important to modify your diet in order to help with meeting enough calorie and protein needs to prevent unintentional weight loss. Unintentional weight loss that happens during cancer therapy and recovery unfortunately predominantly comes from our lean body mass otherwise known as muscle mass which can negatively impact recovery time, fatigue levels and overall well-being. So it is something that we certainly want to avoid. In terms of specific guidance for ways to modify your diet in order to stay well-nourished, this is a really good reason to connect with an oncology dietitian to provide those specific recommendations based on what you're experiencing. Generally speaking things like eating and consuming smaller more frequent meals focusing on foods that are highest in calories and protein are going to be the two hallmark recommendations to in the face of almost any of those side effects to help you with meeting those calorie and protein needs to help with preventing unintentional weight loss. I will be including a handout on what we consider high calorie high protein diet recommendations in the resources I provide to Audrey but generally speaking categories of foods of things like eggs, dairy, animal proteins, so poultry, fish, meat, nuts and beans are all great sources of high calorie high protein foods and something that would be encouraged to include in larger proportions when experiencing any of these side effects. The second group in terms of nutritional priorities would be those individuals who are now beyond that recovery phase of stem cell transplant and are back to what they would consider normal eating in terms of having an adequate appetite and no true challenges getting enough nutrition to maintain weight. We would defer to what we call survivorship nutrition guidance for this group and I want to talk about resources for that in just a moment. For either one of these categories in terms of diet guidance connecting with an oncology dietitian is a great idea. I'm hopeful that many of you who are going through or have gone through a stem cell transplant have had the opportunity to meet and learn and get guidance from an oncology dietitian but I do recognize that staffing at all transplant centers is not always adequate to have access to those individuals. I would start by talking with your treatment team if they have a dietitian they would recommend that you meet with to provide this guidance if you're looking for it. If there is no one within your actual institution where you're receiving the stem cell transplant you can find registered dietitians by going to the academy of nutrition and dietetics which is www.eatright.org. The academy of nutrition and dietetics credentials register dietitians who are the only licensed nutrition professionals in our country and I make that disclaimer just because the word nutritionist does not have any legal liability and you don't necessarily know who you're meeting with and what type of educational background or sorry liability in terms of the guidance they're providing you with so it really is critical to meet with a registered dietitian. You can do so by clicking on find an expert on that main page of the academy nutrition dietetics website and this allows you to search by zip code of where you live as well as by specialty including oncology to find dietitians in your area that you could meet with. In terms of those survivorship nutrition recommendations we are very fortunate that we have very clear up-to-date guidance in terms of guidelines for reducing risk for original cancer occurrence but also helping protect against recurrence so these would be guidelines that once again once you are beyond the recovery phase of a stem cell transplant would be guide and not having any challenges with eating and drinking in terms of barriers to getting enough calories and protein what we would recommend. These guidelines are something that we have 10 guidelines put together from thousands and thousands of research studies and this information is available on the American Institute for Cancer Research and if anyone here in attendance is interested we have classes that are offered once a month through Life with Cancer one of the organizations that I work for that are virtual that go through over a 90 minute time frame all 10 of these guidelines and explain the science behind them and how to best implement them. Please feel free to register for this class the next one is coming up in three weeks and I am teaching it so you are more than welcome to join at any time they are typically starting at five o'clock eastern standard time so just depending on your time zone but if that the next class does not work once again we offer this every single month through Life with Cancer and the class is entitled Survivorship Nutrition. Lastly I want to leave you with what I would consider reliable resources for correctly interpreted evidence-based nutrition information as it relates to nutrition and cancer. The American Institute for Cancer Research in my professional opinion is one of the best resources for well translated information as it relates to nutrition and cancer. Their website is www.aicr.org and we'll talk a little bit more on the next slide of some of the unique opportunities that you can find on their organization's website. The American Cancer Society is absolutely a reliable resource for nutrition and cancer and information. I don't find their resources as robust at times as the AICR in terms of implementing these recommendations but it is absolutely a reliable resource that can be trusted. The Oncology Dietetics Practice Group is a group within the Academy of Nutrition and Dietetics that credentials register dietitians like myself in being oncology certified specialists. This is a website that again is a very reputable and trustworthy source for information if you're looking for resources on nutrition and cancer. Another kind of highlight of AICR for those that are looking for recipe ideas, they have an amazing group of recipes that can provide you with guidance with meals that are consistent with our prevention and survivorship recommendations but honestly could be utilized really at any time during treatment and just focusing on the nutritional priorities in terms of protein in that meal as we briefly discussed. They also have things like a healthy challenge and the iThrive plan which are geared towards helping you and guiding you virtually to help with following a lot of the nutrition guidance that is provided in their research-based guidelines. So I would really encourage people to explore the resources on that website if they haven't already. And with that said, certainly we're going to have plenty of time for questions today which is great. However, if you think of any questions moving forward after this presentation, you have my direct contact information and I would not hesitate to reach out by email to ask me any questions that I can help provide clarification on. And with that said, I will stop sharing. Wonderful, thank you so much. That was an excellent presentation, exactly what I was looking for and I loved how thorough you were with your references and also just taking the time to explain it all. Thank you so much. I felt like you were super clear. I'm going to ask you a couple questions to get started. There are some questions already in the queue but I want to give time for more people to enter their questions. I know you went over this a little bit but let's talk a little bit more about what do you counsel your clients to do when it comes to accepting food from other people. Of course you can tell other people these are the guidelines that you have to follow. Well-meaning people can sometimes not follow those things. So does your general rule of them don't really accept things from people or you know lots of church groups want to give, lots of people in the neighborhood want to help but with these restrictions, what's your general advice? Yeah, so I think like most answers which are a little bit frustrating, and I always teach my interns when they're with me, I have to start with, well it depends. And so what I would say it depends on is you're providing good examples of various groups that potentially provide this assistance and support. If you really don't have any idea what's going on in someone's kitchen even though you've gone to church with them on Sunday for five years, it's probably not best practice if you will to accept food from that individual that you're going to be consuming. If you're the individual that's at highest risk for food porn illness. And why I say that is because maybe we accepted another household members that are at less risk are still capable of consuming it. And that said, I think that's a very different relationship than a neighbor of 25 years that you are at their house all the time, know what their, you know, what precautions they're taking and what their kitchen looks like, and inform them. You know, I think that there can be in my experience, a little bit of hesitation when anyone's trying to offer help of saying, hey, but you can help me. However, I need you to do x, y, and z. But this is for your health. And if they are trying to help you, I know that they'll be receptive if presented in a very polite way of saying, my clinical team has told me that I really need to be cautious at this point in time in terms of food porn illness. Would you mind assuring me that these are food safety practices that you're performing? Or, you know, the other thing that I would say right now that many people often find easier in this day and age, and I will say I think this has evolved in the course of the pandemic, but I know for personal family members and friends, gift cards are a great idea in terms of things like delivery. And so that's another option if the person really doesn't feel comfortable assuring you of their food safety practices, that that would be another option of ways to help. I know those can be challenging conversations, for sure. But when it comes down to it, we got away the risk and benefit and the benefit of avoiding that illness is really just so critical at that point in time. So yeah, that was one of my follow up questions was how can we do this politely? And I think using those handouts that you're going to be sending, even just sending, giving that to a loved one and saying, thank you so much. These are the precautions that my medical team has asked me to take. Exactly. I love it. And kind of, for lack of better terms, punting. It's not that you're being over-precautious, even though you're doing that for your own health, but rather, no, this is literally like a prescribed diet that my clinicians have told me, which is the truth. So I think that that's very reasonable to use that verbiage and those resources. Good. And we talked a little bit about food services, but let's talk about HelloFresh or those others that served basically the pre-made ingredients to your door. Do you recommend those for patients or are you more on the side of make sure you're aware of what's being bought? Yeah. So I wouldn't say particularly, when we're talking about the highest risk for infection, it would be really in those first few weeks after leaving the hospital after a transplant. Right. And so I don't think generally speaking, I have found in my practice that that is a resource that's overtly helpful. They have a lot of prepackaged individual ingredients, but you still really have to prepare the meal. And so I haven't had many individuals use it at that point in time. And it's not something that I would say I would be overtly concerned with, but similarly, I can't emphasize enough the utility of contacting companies to learn about those practices. I can't tell you over the course of 13 years how many companies I've individually called to just say, what can you guarantee me here? And so I think if you explain to a company like HelloFresh or Purple Carrot or what have you, this is again, I need to be very cautious. Can you assure me of your food safety practices? And if they really can't, that would be a limiting factor. And so I would think that that would probably be someone, if you were utilizing that even prior to the transplant and wanted to continue providing that reassurance to yourself and your caregivers is probably a good idea. Yeah. What about if you have somebody like Instacart or grocery delivery or your neighbor offers to go get groceries, is that something that you would be nervous about or just be extra careful to wash the vegetables and fruits when they came in? Yeah, I think again, would be a little bit person dependent. So a teenage boy that may not take it seriously, the neighbor's son or something versus a family member and how long they have to travel between the store and what they're purchasing for you. So things that are pre-packaged and don't need to be refrigerated, we're pretty relaxed about, but when you're talking about produce, meats, et cetera, that would be something I would be much more cautious about if you don't trust the individual in terms of them coming directly to your home and maintaining appropriate temperatures. And so I think that it would be kind of dependent on what you're purchasing and distance from the grocery store and those types of things. But if you were ever unsure trying to focus on that individual, trying to help you purchasing things that are shelf stable for that period of time and having more trustworthy caregivers try to purchase the other things that might be a little bit more risky in terms of maintaining temperatures would be a good idea. Yeah, that makes sense to me. Thank you. Quite a few questions about how long these precautions go for. Yeah, so good question. And this is something, again, bringing me back to my early days. So as we discussed those initial restrictions, if you will, so I remember when I was first practicing, depending on the type of transplant, we would recommend following those neutropenic diets for 30 or 100 days. To be very clear, those are relatively speaking arbitrary guidelines, right? It's not that at day 31, you are then free of risk of foodborne illness. It's just that generally speaking, that's when medical oncologists know that it is more likely that your neutrophil count is maintaining a healthy level that would make it lower risk for infection, not eliminating risk, but lower risk, right? And so in that respect, I can't say that there's a specific timeframe, because even the diets we were recommending during those periods of time when these day limits were existing, we've essentially debunked as being actually helpful. What I would say is that the best way to understand your risk for infection and that increase of your consequence of a foodborne illness, if you experienced it, is understanding where your lab levels are specifically in regards to white blood cell count and neutrophils. So less so than that exact day count when you're going to follow up appointments and getting those complete blood cell counts checked, having a discussion with your physician of where those levels are and risk of infection, which is something I bet that they are all doing anyways, is going to give you more confidence in being, you know, I hate to say this, we should all be this cautious. I actually kind of laugh a little bit about these food safety guidelines. This is how we should all eat all the time, because foodborne illness is our risk for everyone. But in terms of if you are going to stray from this guidance, you would want to make sure that you're at a point that your white blood cell and neutrophil counts are consistently within a normal limit, making it a lower risk for obtaining and having severe consequence from infection. What I will tell you from a caveat standpoint, the type of stem cell transplant that is usually provided for multiple myeloma, those timing guidelines that we previously had the very restrictive diets on was usually 30 days after transplant is when they were liberalized. But again, I would not use that in and of itself as a marker of being less cautious and rather communicate closely with your team about the levels of white blood cell counts and neutrophils. And even then, you know, it's not zero to 100, right? It's a gradual change in diet too. Yeah. Vivian is wondering if tofu is okay for somebody who's had a transplant and if so, what is the best way to cook it? Yeah. So yes, if it's pasteurized. So the majority of tofu that is pre-packaged in the grocery store is pasteurized. But again, just getting that reassurance that, you know, looking on the front of the package label and if it's not clear, calling the company that produces it is completely fine. So pasteurized, you're good to go and cooking it in whatever way that you prefer. So personally, I like to saute it with some spices, but you know, it's up to you. No, it's something that you certainly can enjoy as long as pasteurized, similar to dairy products. Make sure you press it so it's not soggy. Yeah. Which can take a while. Yes. Matt is wondering if there's any restrictions in terms of sauces, seasoning, or peppers? So again, this was something that I think in our most extreme forms of neutropenic diets, we were restricting historically. And so I am not familiar with any clear evidence of increase risk for foodborne illness with the use of things like black pepper on food. I think this was being slightly, if you will, over-precautious with, once again, good intent. No one's questioning the intention of these restrictions. But at this point in time, it's not something that at our institution we recommend based on those updated guidelines from ASCO and IDSA. And so not something that I would recommend avoiding. But once again, we can't certainly ignore common sense. And so if you have at a restaurant, there's an open bowl of black pepper or spices that you don't know who's gone in there with what might be something good to avoid. But generally speaking, the spices you would purchase for yourself in the grocery store or that are prepackaged when eating out or in a container should be completely fine to consume. Yeah. And in terms of sauces, I know you mentioned looking out for the more egg-based sauces, but other than that, these are the same. Exactly. And so same thing in terms of bottled sauces that are pre-made in the store. Again, just pasteurized. Salad dressings are probably that biggest category of some unclarity. And then in terms of other things that might be near the deli section, again, just asking questions if it's really not clear to you what's in there that could be concerning. And then at a restaurant, you know, making sure that you're aware of what's going into those foods. If it's not clear on the menu, just ask your waiter and they should be able to provide you with that guidance. Great. Thank you. Vivian's wondering if it's okay to make salt water for gargles and keep it refrigerated for several days, pouring from that multiple times a day. Yeah. I think as long as you're keeping in the refrigerator, that makes sense. The idea that wouldn't be anything really related to the water, but more bacteria that might be coming from your mouth on the container. So, you know, might just be another level of safety to have it in the one container and pour it into a glass each time that you're utilizing it. It's fine. Awesome. And then last question here is smoked fish such as smoked salmon. What's your opinion on that? Yeah. So that unfortunately does still need to be cooked, which kind of negates the point of the smoked salmon. You can still cook it and it's still tasty if you want that flavor, but it is something that doesn't eliminate that risk, unfortunately, of the same way that we can with cooked fish. So things like lox and smoked salmon are something that unless you are physically cooking them, kind of, you know, I would put this somewhere in the area between deli meat and uncooked fish. But again, if you're really looking for that flavor, I can assure you, because I've had to prepare this for family members myself that needed things that lower bacteria, that it still maintains that smoked flavor, even though it's cooked. So, okay, tasty. Good to know. A couple more questions, so we'll just hit on them. Yeah, that's fine. I'm finishing up. One question is, if this is recorded. Yes, it is. And it's something that you can access. I will send out an email to all registrants within 48 hours with those resources that have been mentioned today and the recording. So just so everybody knows that that is coming your way since you registered. And then that is wondering, is it possible and have you seen people develop any food allergies after the transplant due to their change of immune system? This is a great question. Yeah, I have not, but you are sparking a good question that did come up when I was working in transplant. And it's interesting, I actually, this even short of allergies, even things like food preferences, people sometimes tell me the change. I would have to defer to our allergy specialist to talk about the mechanisms that could drive that change. I'm not, my lens being oncology and not allergies, I'm not familiar with what pathophysiology would connect the two necessarily, because based on it's an IgE mediated response in the body. I don't think it's impossible, but the other thing that might make this tricky is that unfortunately, and certainly I feel bad for these individuals, I also do absolutely see individuals that develop allergies outside of transplant just in adulthood, and even outside of these treatments. So I think that that might make it complicated to discern. But that's a good question that I can't tell you that I've seen, but doesn't seem impossible based on the changes that happen when you get a new immune system. Yeah, and I've definitely heard of more sensitivity to dairy, things like that. But it's a great question to ask an allergist. Maybe you guys should get an allergist on. Exactly, exactly. New topic event. Exactly. All right. Well, thank you so much for your shared time and knowledge. We really appreciate you being with us. You're welcome. You're welcome. Have a great day. Thank you. You too. Bye. You can join us next month in our stem cell transplant chapter meeting for the role of maintenance therapy after stem cell transplant. When does maintenance therapy begin? How long does it last? And why is it used? That will be an excellent discussion. We're just working on that date there with our speakers, so we'll make sure to contact you guys as soon as possible. When that's ready to register for you, you will be notified because you signed up for today's event. Tonight, we're having a different discussion. Northeast Myeloma Community Chapter, we're switching gears and talking about how to navigate myeloma in a world that's moving on from COVID. This is going to be a patient to patient, caregiver to caregiver based discussion. We're not going to be hearing from any doctors, and this is not to shame anyone or to argue about different points of COVID precautions, but we did want to validate the experience of those who are immunocompromised going through as the world moves on from their COVID precautions, how should myeloma patients respond and how are they responding? We wanted to have that discussion together. Then on the 19th at 1 p.m. Eastern is our MGUS Smoldering Myeloma Chapter. We're going to be discussing emerging research in the smoldering myeloma field with Dr. Kazanjian. On the 19th at 1 p.m. Eastern is our Florida Myeloma Chapter. It's cancer survivorship optimizing your wellness, and that will not be recorded, so if you'd like to attend on the 19th, please attend live. The link to sign up for any of those events and even more events I did not mention is found at the bottom of this slide and will be sent out in that email that I've referenced within 48 hours. Another thank you to our sponsors, Bristol Myers Squibb, GSK, Genentech, Janssen Oncology, and Abbby, and a big thank you to each of you for helping us grow this health tree, oh, excuse me, this health tree myeloma community. I really appreciate all of you. Hope you have an excellent rest of your day. Thank you, everyone. Take care. Bye-bye.